Which physiological change should a nurse expect to observe when assessing an elderly client?
Diminished attention span.
Decreased sensory acuity.
Increased need for rest.
Enhanced intestinal motility.
The Correct Answer is B
Decreased sensory acuity. This is a physiological change that occurs in elderly people due to the reduced function of the sensory organs, such as the eyes, ears, nose, tongue, and skin. Elderly people may experience impaired vision, hearing loss, reduced smell and taste, and decreased touch sensitivity.
Choice A is wrong because diminished attention span is not a normal physiological change in elderly people. It may be a sign of cognitive impairment or dementia.
Choice C is wrong because the increased need for rest is not a normal physiological change in elderly people. It may be a sign of fatigue, depression, or medical conditions.
Choice D is wrong because enhanced intestinal motility is not a normal physiological change in elderly people. It may be a sign of gastrointestinal disorders or infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The first observation the nurse should perform for a client who is receiving from the post anesthesia unit after a colon resection is to assess the patency of the airway and respiratory function.
This is because the airway is the most vital for the survival of the client and any compromise can lead to hypoxia and death.
The nurse should then take vital signs, check the wound dressing, and assess the foley catheter drainage.
Choice A is wrong because the client’s wound dressing is not as important as the airway and can be checked later.
Choice B is wrong because the client’s level of consciousness may be affected by the anesthesia and is not a priority over the airway.
Choice D is wrong because the client’s foley catheter drainage is not a critical observation and can be monitored later.
Normal ranges for respiratory rate are 12 to 20 breaths per minute for adults, oxygen saturation is 95% to 100%, and blood pressure is 120/80 mmHg for healthy individuals.
Correct Answer is B
Explanation
My spouse will just have to put up with any new irritability. This statement indicates that the client requires further educational reinforcement about the medication because phenelzine is an antidepressant that should improve the mood and reduce irritability. The client may also need to be assessed for possible adverse effects of phenelzine, such as agitation, insomnia, or hypomania.
Choice A is wrong because it is a correct statement. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with foods that contain tyramine, such as cheese and caffeine, and cause a hypertensive crisis.
The client should avoid excessive amounts of these foods while taking phenelzine.
Choice C is wrong because it is also a correct statement. Phenelzine can cause orthostatic hypotension, which is a drop in blood pressure when changing positions.
The client should change positions slowly, as dizziness may occur.
Choice D is wrong because it is partially correct. Phenelzine can cause headaches, which may be a sign of a hypertensive crisis.
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